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BRASH-syndrome: case report A 74-year-old man developed BRASH (bradycardia, renal failure, AV-nodal blockade, shock and hyperkalaemia)-syndrome during treatment with lisinopril and metoprolol for hypertension [routes and durations of treatments to reaction onset not stated]. The man, who had a history of type 2 diabetes, hypertension and renal insufficiency, presented to the emergency department with complaints of lip and hand swelling and chest rash. When the paramedics first arrived, he had hypotension with pulse of 40 bpm and BP of 60/30mm Hg. He was started on treatment with epinephrine, famotidine [Pepcid] and diphenhydramine [benadryl] by emergency medical services (EMS). It was reported that, he had been receiving home medications, which included lisinopril 2.5 mg/day and metoprolol 200mg twice a day. Physical examination revealed pulse rate 55 bpm, BP of 80/50mm Hg, sating of 100% (on room air) and respiratory rate of 16. He was diagnosed with anaphylaxis, and emergency physician started him on the treatment with epinephrine, methylprednisolone [solumedrol] and IV fluids. His vital signs remained unchanged, and he was started on epinephrine drip. A right internal jugular central line was placed. His laboratory tests revealed creatinine of 3.09 mg/dL, sodium of 132 mmol/L, potassium of 7.1 mmol/L, glucose of 382 mg/dL and anion gap of 31, which was indicative of diabetic keto-acidosis (DKA). ECG performed while on epinephrine drip showed sinus bradycardia. The man was treated with albuterol, calcium, insulin drip and unspecified broad-spectrum antibiotics. He was then admitted to the ICU. The next day, an improvement was observed in his haemodynamics, and his pressor support was weaned off. His rash and swelling also resolved. Cardiology, nephrology and allergy was consulted, and anaphylaxis with angioedema features was concluded. Based on these findings and clinical presentation it was concluded that hypovolaemia secondary to anaphylaxis and treatment with lisinopril and metoprolol (polypharmacy) resulted in BRASH syndrome. After 7 days hospital course, normalisation of creatinine to baseline was observed. He was discharged in excellent condition. Flores S. Anaphylaxis induced bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia: A-BRASH in the emergency department. American Journal of 803517599 Emergency Medicine 38: 1987e1-1987e3, No. 9, Sep 2020. Available from: URL: http://doi.org/10.1016/j.ajem.2020.05.033

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Reactions 28 Nov 2020 No. 1832